Healthcare Provider Details

I. General information

NPI: 1275580680
Provider Name (Legal Business Name): PHILLIP ALLAN MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 LYNCH CANYON DR
LAKE ISABELLA CA
93240-9726
US

IV. Provider business mailing address

19963 WALKER BASIN RD
CALIENTE CA
93518-4124
US

V. Phone/Fax

Practice location:
  • Phone: 760-379-8630
  • Fax: 760-379-7658
Mailing address:
  • Phone: 661-867-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG61763
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG61763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: